Vital Signs- Chapter 10

temperature, respiratory rate, pulse, blood pressure

What are the objective vital sign
measurements?

facility guidelines

follow _______ for monitoring

clinical judgement

What should you use to determine if additional monitoring is needed?

99

What is the temperature needed for cellular metabolism/ deep temp/ stable core in Fahrenheit?

hypothalamus

What regulates the steady temperature in the brain?

96.4 -99.1

What is the normal range for temperature?

one degree

How much higher is a rectal temperature than an oral temp?

feedback mechanism

(balances heat production from metabolism, exercise, food digestion, external factors with heat loss from radiation, sweat evaporation, convection, conduction)

How does body maintain a steady temperature?

diurnal cycle, menstrual cycle, exercise, age

What can influence body temperature?

early morning hours

When does the body temperature trough in the diurnal cycle?

late afternoon, early evening

When does the body temperature peak in the diurnal cycle?

1 to 1.5 F

What is the temperature range difference in the diurnal cycle?

menstrual cycle

progesterone secretion, occurring with ovulation causes a 0.5-1 F degree rise in temperature that continues until menses

exercise

moderate to severe exercise increases body temp

age

- wider variations for younger people bc of ineffective heat control

- older adults are lower in temp, averaging about 97.2 via oral route

oral

(sublingual pockets are rich in blood supply from carotid arteries that quickly respond to temp changes)

What is the most convenient and accurate temperature site?

blue

What color tip for oral?

15 (mins)

How long should you wait if person consumed hot/cold liquids?

2 (mins)

How long should you wait if person smoked?

rectal

What is the most accurate temperature site?

rectal temperature

- most accurate

- most invasive

- better detects low grade fever than tympanic or temporal artery temp

- best route when patients are comatose, confused, cant close their mouth, wired mandible, facial dysfunction

- uncomfortable and invasive

red

What color tip do you use for rectal?

Left lateral decubitus

the patient is lying on his or her left side.

1 in (insert towards belly button)

How far do you insert rectal thermometer in the rectum?

fever

elevated body temperature

; above 100.4 F

low grade fever

100-100.9 F

tympanic membrane temperature

senses infrared emissions of the tympanic membrane (eardrum)

- same blood supply as internal carotid artery that vascularizes hypothamulus

- not as accurate

- pull ear up and back for adults

hyperthermia

aka fever

- abnormal high body temperature

- caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown ; following MI, trauma, surgery, malignancy, stroke, brain tumor , cerebral edema

body temp higher than 100.4 is fever

hypothermia

abnormally low body temperature

- usually caused by accidental prolonged exposure to cold

- can be purposeful induced to lower body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, post cardiac arrest or GI hemorrhage

- body temp lower than 96.8 F

104 F

40 C

98.6 F

37 C

95 F

35 C

pulse

the force of blood leaving the heart in one heartbeat; it is felt where arteries pass near the skin.

- flares the arterial walls and generates a pressure wave felt in the periphery

stroke volume

the volume of blood pumped out by a ventricle into the aorta with each heartbeat

- typically around 70mL

30 secs ( times by 2)

How long should you count radial pulse?

60 secs

How long should you count radial pulse if irregular?

rate, rhythm, force

What do we assess pulse for?

meds (especially cardiac medicines for those with heart disease)

What can slow down the heart rate?

50-95 (60-100)

What is the normal pulse range?

bradycardia

slow heart rate (less than 50 bpm)

- may occur in well-trained athletes ; stronger more efficient heart What is the most convenient and accurate temperature site pushes out more with each beat

- may occur in patients taking more than one med with negative chronotropic effects

tachycardia

fast heart rate

over 100bpm

- anxiety, exercise, fever, sepsis, pneumonia, MI, pancreatitis

- tachycardia predicts complications and worse survival rates later on

rhythm

pulse has a regular even tempo

strength of heart stroke volume

Force of pulse is

3+

full bounding pulse

- denotes increased stroke volume

- anxiety, exercise, some abnormal conditions

2+

normal pulse

1+

weak, thready

- reflects decreased stroke volume (hemorrhagic shock)

0

absent pulse

regular breathing

relaxed, regular, automatic, silent

30 seconds

How long do you count breaths for?

abnormal breathing

labored, shallow, dyspnea, deep, accessory muscle use including belly breathing, nose flaring, supraclavicular, ribs, intercoastal breathing

4:1

What is the constant ratio of pulse rate to respirations?

12-20

respirations range

males

What gender has a slightly faster HR after puberty?

blood pressure

force of the blood pushing against the side of the vessel wall

- systolic and diastolic

systolic

maximum pressure felt on artery during left ventricular contraction/ systole

diastolic

elastic recoil, or resting, pressure that blood exerts constantly between each contraction

pulse pressure

difference between systolic and diastolic pressure and reflects the stroke volume

good= 30-50mmHg

Mean arterial blood pressure (MAP)

pressure forcing blood into the tissue average
over the cardiac cycle

MAP= 2 times diastolic + systolic /3

--- need a MAP greater than or equal to 60mmHg to maintain adequate tissue and
organ perfusion

age (normal rise through years),

sex (higher in women after menopause),

race (blacks have higher than non black),

diurnal rhythm (high in afternoon , lower during sleep)

weight (bp higher in obese)

exercise ( increases temporarily)

EMOTIONS (fear, anger, pain increases BP due to sympathetic NS)

stress (higher BP)

What factors influence BP?

cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, elasticity of vessel walls

What are the 5 factors that determine BP?

cardiac output

heart rate x stroke volume

- if heart pumps more blood into the blood vessels, pressure on the walls increases

peripheral vascular resistance

opposition to blood flow through arteries; when vessels becomes smaller or constricted pressure needed to push becomes greater (vasoconstriction)

vasodilation= less pressure needed

- common medication side effect

volume of circulating blood

refers to how tightly blood is packed into arteries; increasing contents in vessels increases pressure

- ex: blood transfusion increases volume and hemorrhage decreases volume

viscosity

thickness of the blood determined by its formed elements, the blood cells

contents thicker= more pressure

elasticity of vessel walls

when vessel walls are stiff and rigid, pressure needed to push contents through increases

bradypnea

Slow breathing (less than 10/min)

tachypnea

rapid breathing (more than 22/ min)

40%

What percentage should the width of the rubber bladder equal with the circumference of the arm?

falsely high BP (due to extra pressure to compress the artery)

What does using a cuff that is too small do?

heart level

Where should the arm be during blood
pressure?

flat

How should pt feet be during BP?

auscultatory gap

a brief period when Korotkoff sounds disappear during auscultation of blood pressure; common with hypertension

to avoid missing an auscultatory gap

Why do we inflate 20-20mmHg above the first step?

less than 120/80

What is normal blood pressure?

120-129/less than 80

What is elevated blood pressure?

130-139/80-89

What is high blood pressure stage 1?

140+/90+

What is high blood pressure stage 2?

180+/120+

What is a hypertensive crisis?

Korotkoff sounds

series of sounds that correspond to changes in blood flow through an artery as pressure is released

nothing

What should you hear if the cuff is correctly inflated?

tapping

What should you hear in Korotkoff phase 1?

silence (diastolic)

What should you hear in Korotkoff phase 5?

taking while active/following activity/ emotionally labile

narrow cuff size, applied too loose

reinflating during procedure, anxious, angry, legs crossed

What are common BP mistakes that lead to high readings?

decreased inflation, too large cuff size,

What are common BP mistakes that lead to low readings?

position of arm/leg, improper cuff size, deflating too quickly, assumption regarding person weight, faulty technique or equipment

What can be some observer/examiner mistakes which can lead to high/low readings?

orthostatic vital signs

blood pressure & pulse taken lying, sitting, & standing and documented indicating the corresponding position

- suspected volume depletion

- person known to have hypertension/taking antihypertensive meds

- person reports fainting or syncope

- normal findings are less than 10mmhg in systolic, anything higher is bad

When should you take orthostatic or postural vital signs?

syncope

"Passing out", loss of consciousness or fainting

orthostatic hypotension

low blood pressure that occurs upon standing up

- drop in systolic more than 20mmHG and 10mmhg diastolic when standing up

- caused by changes by abrupt peripheral vascularization without a change in cardiac output

- occurs with prolonged bed rest, old age, hypovolemia, some meds

3 mins

How long should pt rest between vital readings? (ortho BP)

(aging adult) temperature

- changes in body's temp regulation

- less likely for fever; more likely for hypothermia

-sweat glands activity diminished
- sweat glands activity diminished

(aging adult) pulse

- normal range of HR is 60-100 bpm

- increase in radial artery rigidity

- pulse easier to palpate

(aging adult) respirations

Aging causes a decrease in vital capacity and a decreased inspiratory reserve volume.

- You may note a shallower inspiratory phase and an increased respiratory rate.

(aging adult) blood pressure

- aorta and major arteries harden with age
- systolic pressure increases leading to widened pulse pressure
- both systolic and diastolic increase harder to distinguish normal aging values from hypertension

pulse oximeter

noninvasive method to assess arterial oxygen saturation

- sensor attached to person's finger or ear lobe has diode and emits light and detector measures relative amount of light absorbed by oxyhemoglobin HbO2 and unoxygenated Hb

-- compares ratio of light emitted to light absorbed and converts this ratio to percentage of oxygen saturation

doppler techniques

-Pulse and BP measurement is enhanced by using an electronic device, Doppler ultrasonic flow meter.

-Sound (blood pumping through artery) varies in pitch in relation to distance between sound source and listener: pitch is higher when distance is small, and pitch lowers as distance increases.

-Handheld transducer picks up changes in sound frequency as blood flows and ebbs, and it amplifies them.

hypotension

seen in acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's disease

less than 95/60mmHg for normal

hypertensive adults = greater than 95/60mmHg

patients with low perfusion (hypothermia, vasoconstriction), low hemoglobin, dyshemoglobenemias, dark nail polish,

When is finger location not good for pulse ox?

decreased cardiac output

Hypotension occurring from acute MI or shock is because of ?

decrease in total blood volume

Hypotension occurring from hemorrhage is because of ?